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About Us
Our Homes & Services
Contact Us
Client Application
Client Agreement
Apply For Hammock Home
Application Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Email
Primary Telephone Number
Social Security Number (optional)
Zip
Address
State/Province
City
Application - Employment Info
Employer Name
Phone Number
Date of Birth
Manager Name
Are you currently employed?
Yes
No
What date do you need housing?
Phone Number
Address
Agencies that work with you for housing
Case Manager
DOC Number
Have you lived in transitional housing before?
Yes
No
When?
Organization
Please share your experience there
Have you ever been convicted of a violent offense? Including DV?
Are you a registered sex offender?
Yes
No
Have you been convicted of arson?
Yes
No
Pending charges or warrants?
Yes
No
Parole or Probation Officer Name and Phone
If yes, please explain
County
Status
Are you on DOSA?
Yes
No
Do you require mental health treatment?
Yes
No
Do you require mental health treatment?
Yes
No
Are you currently receiving mental health treatment?
Yes
No
Do you require daily assistance from a provider?
Yes
No
Have you been prescribed any medications?
Yes
No
Are you taking your medications as directed?
Yes
No
Are you enrolled in a MAT program?
Yes
No
If yes, list each medication and dosage
Physician Name
Physician Phone Number
Mental Health Provider Name
Mental Health Provider Phone Number
Drugs of choice
Any chemical dependency treatment IOP, OP past or present
Yes
No
If Yes, do you receive services
Yes
No
If yes, where?
Last Used Date
Do you plan to attend 90 meetings in 90 days?
Yes
No
Personal Statement – Tell us about yourself
With limited beds available, what makes you the best fit for this House?
Self Pay
Yes
No
SSI
Yes
No
Voucher
Yes
No
How long?
Other
Yes
No
Explain
Submit
